Regional changes in charcoal-burning suicide rates in East/Southeast Asia from 1995 to 2011: a time trend analysis

Examining the Spread of Charcoal-Burning Suicide in Taiwan

Background: Charcoal-burning has become a predominant method of suicide in many East-Asian countries since the 1990s. Aims: To explore charcoal-burning suicide trends from 1996 to 2020 in Taiwan. Methods: Joinpoint regression models were applied to identify suicide trends over the study period. Decompositional analyses quantified the contributions of age, sex, suicide method, and area of residence to suicide rate trends, accounting for age and geographical distribution of the general population, with a focus on charcoal-burning suicide. Results: There were three stages of suicide rate trends: increasing (1996-2006), descending (2006-2011), and levelling-off (2011-2020). Suicide by charcoal-burning accounted for 70% of the increasing suicide rates between 1996 and 2006 and 50% of the decreasing rates in the descending stage (2011-2020). During the levelling-off stage, suicide by charcoal-burning continued to decrease, albeit slowly. During the descending stage, there was a partial "substitution" of jumping for charcoal-burning. During the levelling-off stage, suicide by hanging partially "substituted" for suicide by charcoal-burning. Limitations: The variables included were limited by data availability. Conclusions: Charcoal-burning remains the second most common method of suicide in Taiwan today. Charcoal-burning has been partially replaced in the last 10 years by jumping and hanging. Monitoring suicide methods and trends is essential for suicide prevention interventions.

Carbon Monoxide Poisoning: From Occupational Health to Emergency Medicine

Carbon monoxide poisoning remains a leading cause of accidental poisoning worldwide (both at home and at work), and it is also a cause of suicidal poisoning. Such poisoning can arise following prolonged exposure to low levels of CO or following brief exposure to high concentrations of the gas. In fact, despite exposure limits, high safety standards, and the availability of CO alarms, nearly 50,000 people in the United States visit the emergency department each year due to poisoning. Additionally, CO poisoning in the United States causes up to 500 deaths each year. Despite the widespread nature of this form of poisoning, known about for centuries and whose damage mechanisms have been recognized (or rather hypothesized about) since the 1800s, early recognition, especially of late complications, and treatment remain a medical challenge. A well-designed therapeutic diagnostic process is necessary so that indication for hyperbaric or normobaric therapy is correctly made and so that patients are followed up even after acute exposure to diagnose late complications early. Furthermore, it is necessary to consider that in the setting of emergency medicine, CO poisoning can be part of a differential diagnosis along with other more frequent conditions, making its recognition difficult. The last thirty years have been marked by a significant increase in knowledge regarding the toxicity of CO, as well as its functioning and its importance at physiological concentrations in mammalian systems. This review, taking into account the significant progress made in recent years, aims to reconsider the pathogenicity of CO, which is not trivially just poisonous to tissues. A revision of the paradigm, especially as regards treatment and sequelae, appears necessary, and new studies should focus on this new point of view.

Recent trends in an uncommon method of carbon monoxide suicide

PURPOSE

The most prevalent method of carbon monoxide (CO) suicide is inhalation of vehicle exhaust (VE). However, a new method of CO suicide has recently emerged involving charcoal burning (CB) in a confined space to produce fatal CO levels. This method has been reported from countries in Asia, associated with economic instability and media reporting of high-profile celebrity cases. The current study was undertaken to analyze rates and characteristics of CB suicides in South Australia (SA) for comparison with respect to their characteristics and scene, autopsy and toxicology findings.

METHODS

A search was undertaken for all intentional fatal carbon monoxide poisonings in SA between 2000 and 2019. Collected variables included age, sex, cause of death, location of death, decedent histories, scene, autopsy and toxicology findings and manner of death. Statistical analyses were performed using R (version 4.2.3).

RESULTS

There was a significant decrease in VE suicides (p < 0.05) and a significant increase in CB suicides (p < 0.001) over the 20-year period. Those who used CB were found to be, on average, between 1.5 and 15.8 years younger than those who used VE (p = 0.017). The risk factors for CB suicide included psychological/psychiatric conditions and financial problems, while VE suicides were associated with a history of physical problems and contact with the legal system. External and internal autopsy findings were consistent with the literature.

CONCLUSION

CB suicide is perceived to be widely accessible and painless and is therefore becoming a popular suicide method. Monitoring future trends will be important to determine whether intervention is required.

Effectiveness of a Suicide Prevention Lethal Means Training Program for the General Public

To evaluate the effectiveness of Conversations on Access to Lethal Means for the General Public (CALM-GP), a training for the public focusing on reducing access to lethal means during a crisis. The program adapted Counseling on Access to Lethal Means (CALM), developed for mental health practitioners and physicians. Participants completed pre/post surveys and follow-up surveys three months afterward. Measures included comfort and confidence in talking to a suicidal individual about access to lethal means, the likelihood of follow-up, and the number of lethal means conversations before and after the program. Surveys showed improvement in comfort and confidence talking about safely storing firearms and other lethal means and the likelihood of follow-up with that individual regarding access to lethal means. Results also indicated increased conversations participants had regarding suicide and lethal means at three-month follow-up. This evaluation suggests that CALM-GP is an effective suicide prevention and lethal means program for the public.

Increased Long-Term Risk of Dementia in Patients With Carbon Monoxide Poisoning: A Systematic Review and Meta-Analysis of Cohort Studies

OBJECTIVE

To assess whether carbon monoxide (CO) poisoning increases the incidence of dementia.

METHODS

We searched the Cochrane Library, PubMed, and EMBASE from inception to 14 August 2022. Two authors independently selected studies, assessed the quality of included studies, and extracted data. Any disagreement was resolved by discussion with a third author. Only cohort study with an enough follow-up period was included for systematic reviews and meta-analysis.

RESULTS

Thirty-three full texts were initially searched, but only three studies met our inclusion criteria, and they were comprised of 134,563 participants who were initially free of dementia. The follow-up period ranged from 9 to 12 years. We found that CO poisoning increased the risk of dementia incidence (adjusted hazard ratio 2.61, 95% confidence interval 1.56 to 4.36, p=0.0003). Subgroup analysis showed that the increased dementia risk was significant in males but not in females, and the highest risk was in young age group, followed by in middle age group, but not in the old one.

CONCLUSION

Overall the evidence from prospective cohort studies supported a link between CO exposure and an increased dementia risk, although all the included studies were limited to Taiwanese population.

Predicting acute brain lesions on magnetic resonance imaging in acute carbon monoxide poisoning: a multicenter prospective observational study

An acute brain lesion (ABL) identified by brain magnetic resonance imaging (MRI) after acute carbon monoxide (CO) poisoning is a strong prognostic factor for the development of delayed neuropsychiatric syndrome (DNS). This study aimed to identify predictors of ABLs on MRI in patients with acute CO poisoning. This was a multicenter prospective registry-based observational study conducted at two tertiary hospitals. A total of 1,034 patients were included. Multivariable logistic regression analysis showed that loss of consciousness (LOC) (adjusted odds ratio [aOR] 2.68, 95% Confidence Interval [CI]: 1.49-5.06), Glasgow Coma Scale (GCS) score < 9 (aOR 2.41, 95% CI: 1.49-3.91), troponin-I (TnI) (aOR 1.22, 95% CI: 1.08-1.41), CO exposure duration (aOR 1.09, 95% CI: 1.05-1.13), and white blood cell (WBC) (aOR 1.05, 95% CI: 1.01-1.09) were independent predictors of ABLs on MRI. LOC, GCS score, TnI, CO exposure duration, and WBC count can be useful predictors of ABLs on MRI in patients with acute CO poisoning, helping clinicians decide the need for an MRI scan or transfer the patient to an appropriate institution for MRI or hyperbaric oxygen therapy.

Spatial and temporal trends and risk factors for intentional carbon monoxide poisoning hospitalizations in England between 2002 and 2016

INTRODUCTION

Suicide and mental health disorders are a recognized increasing public concern. Most suicide prevention rely on evidence from mortality data, although suicide attempts are a better predictor for completed suicides. Understanding spatio-temporal patterns and demographic profiles of people at risk can improve suicide prevention schemes, including for carbon monoxide (CO) poisoning, a common method for gas-related suicides.

OBJECTIVE

Describe spatio-temporal patterns of intentional CO poisoning hospitalization rates in England between 2002 and 2016, and identify population sub-groups at risk.

METHODS

We used NHS Digital's Hospital Episode Statistics (HES) routinely collected data on hospital admissions for intentional CO poisoning. We estimated age-standardised rates (ASR) by year, gender and residential small-area characteristics, including rural/urban, deprivation and ethnic composition. Temporal trends were assessed through linear regression and joinpoint regression analysis. Regional differences were explored.

RESULTS

On average, we identified 178 hospital admissions for intentional CO poisoning per year. The ASR decreased substantially over the study period, particularly among males (average annual percent change of -7.8 % (95 % CI: -11.0; -4.6)), in comparison to 3.9 % (95%CI, -6.4; -1.4) among females. Most admissions (81 %) occurred in males. White men aged 35-44 years were particularly at risk. The ASR in London (0.08/100,000) was almost six times lower than in the South-West (0.47/100,000).

CONCLUSIONS

This study provides novel insights into attempted suicides by intentional CO poisoning. Further prevention interventions, targeting sub-groups at risk (i.e. white men in their 30s/40s), need to be developed and implemented to reduce the burden of suicides and of CO poisoning.

Suicides by pesticide ingestion in Pakistan and the impact of pesticide regulation

INTRODUCTION

Suicide is a major public health problem in Pakistan, accounting to approximately 19,331 deaths every year. Many are due to consumption of acutely toxic pesticides; however, there is a lack of national suicide data, limiting knowledge and potential for intervention. In this paper, we aimed to review the literature on pesticide self-poisoning in Pakistan to identify the most problematic pesticides in relation to national pesticide regulations.

METHODS

Information on the currently registered and banned pesticides was obtained from Ministry of National Food Security and Research while data on pesticide import and use was extracted from FAOSTAT. We searched the following sources for articles and research papers on poisoning in Pakistan: Cumulative Index to Nursing and Allied Health (CINAHL), Google Scholar, Applied Social Sciences Index and Abstracts (ASSIA), Excerpta Medica (EMBASE), National Library of Medicine's MEDLINE (PUBMED), PS102YCHINFO and Pakmedinet.com using the search terms 'self-poisoning', 'deliberate self-harm', 'suicide', 'methods and means of suicide', 'organophosphate', 'wheat pill', 'aluminium phosphide', 'acute poisoning', OR 'pesticides', AND 'Pakistan'.

RESULTS

As of May 2021, 382 pesticide active ingredients (substances) were registered in Pakistan, of which five were WHO hazard class Ia (extremely hazardous) and 17 WHO hazard class Ib (highly hazardous). Twenty-six pesticides, four formulations, and seven non-registered pesticides had been banned, of which two were WHO class Ia and five Ib. We identified 106 hospital-level studies of poisoning conducted in Pakistan, of which 23 did not mention self-poisoning cases and one reported no suicidal poisoning cases. We found no community or forensic medicine studies. Of 52,323 poisoning cases identified in these papers, 24,546 [47%] were due to pesticides. The most commonly identified pesticide classes were organophosphorus (OP) insecticides (13,816 cases, 56%) and the fumigant aluminium phosphide (3 g 56% tablets, often termed 'wheat pills'; 686 cases, 2.7%). Few studies identified the particular pesticides involved or the resulting case fatality.

CONCLUSION

We found pesticide poisoning to be a major cause of poisoning in Pakistan, with OP insecticides and the fumigant aluminium phosphide the main pesticides identified. Withdrawal of Class I pesticides (as proposed to occur nationally in 2022) and high concentration aluminium phosphide tablets should rapidly reduce suicidal deaths by reducing the case fatality for low-intention poisoning cases. National cause of death data and forensic toxicology laboratory data identifying the pesticides responsible for deaths will be important to assess impacts of the proposed national ban.

The evolution of charcoal-burning suicide: A systematic scoping review

INTRODUCTION

Suicide by charcoal burning has accounted for more than 100,000 deaths. It has become an increasingly common suicide method in Hong Kong since first reported in 1998, and it has spread into South Korea, Taiwan, Japan and other countries. This systematic scoping review aimed to explore current evidence on trends, risk factors, impact of media and prevention strategies for this suicide method, and to identify research gaps.

METHODS

A search for articles published from January 1998 to June 2021 was conducted through electronic databases (MEDLINE, EMBASE, SCOPUS and PsycINFO) with the keywords (suicide*) AND (charcoal). Articles describing prevalence, trends, characteristics, risk factors and prevention strategies of charcoal burning suicide deaths were included. Non-peer-reviewed articles, non-English articles, commentaries/editorials/letters, poster abstracts, reviews, meta-analyses and studies that documented only charcoal burning suicide attempters/survivors were excluded.

RESULTS

Eighty-eight studies were identified, most from East Asia. Charcoal burning suicide rates in Hong Kong, Taiwan and Japan has passed the peak, while continuing to increase in South Korea. Risk factors are changing and not static. Media appears to play an important role in triggering and spreading information. Restricting access to charcoal, and raising public awareness have been effective in the short term in preventing charcoal burning suicide, but there is little information on their long-term effectiveness or sustainability.

DISCUSSION

More research is required to update the development and dynamic changes of charcoal burning suicide and the contributing factors. The evidence from this review may assist in detecting and intervening early for future novel suicide methods.

Incidence, risk and protective factors for suicide mortality among patients with major depressive disorder

AIM

Patients with major depression have greater suicide mortality, but there is no data on the standardised mortality ratio (SMR) and factors for suicide of major depression for Asian countries. This research estimates the SMR and the risk and protective factors for suicide mortality in patients with major depression in a large-scale Asian cohort.

METHODS

Patients with major depression (N = 1978) admitted to a psychiatric hospital in Taiwan between 1985 and 2008 were enrolled as the study cohort. When the cohort was linked to the national mortality database, 415 deceased patients were identified. Of these 415 deaths, 107 were from suicide. Nested case-control with risk sampling was used, where each case was matched with two controls. Clinical information was collected through a standardised chart review process. The SMR for suicide mortality was estimated, and a conditional logistic regression analysis was performed to determine risk and protective factors for suicide.

RESULTS

Patients with major depression had high all-cause and suicide mortality, with SMRs of 3.9 and 35.4, respectively. Agitation (adjusted risk ratio [aRR] = 2.85, P = 0.058), restlessness (aRR = 15.05, P = 0.045) and previous suicide attempts (aRR = 4.48, P = 0.004) were identified as risk factors for suicide mortality. By contrast, those with employment (aRR = 0.15, P = 0.003) or loss of interest (aRR = 0.32, P = 0.04) had lower risk.

CONCLUSIONS

Patients with depression exhibited higher suicide mortality. Clinical staff should pay close attention to risk and protective factors to reduce suicide risk.

An artificial intelligence algorithm for analyzing globus pallidus necrosis after carbon monoxide intoxication

Globus pallidus necrosis (GPN) is one of typical neurological imaging features in patients with carbon monoxide (CO) poisoning. Current clinical guideline recommends neurological imaging examination for CO-intoxicated patients with conscious disturbance rather than routine screening, which may lead to undiagnosed GPN. We aimed to develop an artificial intelligence algorithm for predicting GPN in CO intoxication patients. We included CO intoxication patients with neurological images between 2000 and 2019 in Chang Gung Memorial Hospital. We collected 41 clinical and laboratory parameters on the first day of admission for algorithm development. We used fivefold cross validation and applied several machine learning algorithms. Random forest classifier (RFC) provided the best predictive performance in our cohort. Among the 261 patients with CO intoxication, 52 patients presented with GPN. The artificial intelligence algorithm using the RFC-based AI model achieved an accuracy = 79.2 ± 2.6%, sensitivity = 77.7%, precision score = 81.9 ± 3.4%, and F1 score = 73.2 ± 1.8%. The area under receiver operating characteristic was approximately 0.64. Top five weighted variables were Platelet count, carboxyhemoglobin, Glasgow Coma scale, creatinine, and hemoglobin. Our RFC-based algorithm is the first to predict GPN in patients with CO intoxication and provides fair predictive ability. Further studies are needed to validate our findings.

The differential impacts of social deprivation and social fragmentation on suicides: A lesson from Hong Kong

INTRODUCTION

Little research has conducted to examine the association between social deprivation and social fragmentation, overall and method-specific suicide risk, and how these associations may change over time. This study investigated the association between social deprivation and social fragmentation with overall and method-specific suicide in Hong Kong from 1999 to 2018.

METHODS

Suicide death data of each small tertiary planning unit (STPU) was obtained from the Census and Statistics Department of Hong Kong. Socio-economic characteristics in STPU level were obtained from Census and Bi-census. Exploratory principal component analysis was used to construct the social deprivation (SDI) and social fragmentation indices (SFI) based on the socio-economic characteristics. Bayesian hierarchical modelling was conducted to explore the association between SDI and SFI with overall and method-specific suicide over time, controlling for population density and male-to-female ratio.

RESULTS

Higher risk of suicide was generally observed around Kowloon Peninsula and some parts in the Northern, Northwestern and Southwestern areas depending on methods. The effect of SDI and SFI on suicide risk varied by years and methods. In 2014-2018, for every 10% increase in SDI, the suicide risk for overall, jumping, hanging, and charcoal burning elevated by 22% (95%Crl = 10%-37%), 26% (95%Crl = 12%-41%), 31% (95%Crl = 14%-51%), and 21% (95%Crl = 4%-42%) respectively.

CONCLUSION

Spatial variations and effects of SDI and SFI on overall and method-specific suicide risks varied by different periods. SDI was observed to be a stronger factor in the recent years. Situations should be monitored, and interventions should be implemented and adjusted accordingly to the changes.

An evaluation of the long-term sustainability of suicide prevention programs in an offshore Island

INTRODUCTION

In 2002, a suicide prevention program for visitors was implemented in Cheung Chau, an offshore island with 21,000 residents and many visitors. This research revisited the intervention and evaluated its long-term effectiveness. Insights are provided into implementing a sustainable intervention.

METHODS

Suicide death records (2007-2017) of Cheung Chau residents and visitors were retrieved. Information related to suicide method and sociodemographic characteristics of people who died by suicide were explored. Bivariate analyses were conducted to examine differences between visitors and residents; visitors and residents who died in Cheung Chau; and residents who died in or outside Cheung Chau.

RESULTS

After post-implementation period, suicide rate for visitors and residents increased. Visitors were generally younger than the residents with a different distribution of type of housing. Most of the visitors killed themselves by charcoal burning, and nearly half of the residents used hanging.

CONCLUSION

Long-term evaluation and monitoring of suicide prevention programs and sustained efforts are crucial to ensure program success. The prevention program in Cheung Chau was initially effective, but its long-term effects wore off. Both the mental health needs of visitors and residents should be addressed. Refinement of the current program and sustainable efforts are required for ensuring long-term success.

Perceptions towards charcoal-burning suicide and the surge of this lethal method in Taiwan

Objective

Whether sociocultural perceptions of charcoal-burning suicide have influenced its rapid increase in prevalence is unclear. We aimed to explore perceptions of Taiwan’s general population regarding charcoal-burning suicide, their personal belief in life after death, and related feelings of thoughts associated with those who attempt charcoal-burning suicide.

Methods

An online web-based survey, focussing on sociocultural attitudes towards death, as well as perceptions towards charcoal-burning suicide, and those who attempt charcoal-burning suicide, was conducted from 14 January to 14 June 2016.

Results

In total, 1343 adults completed the online survey (mean age of 33.46; 66.6% women). Notably, 90.3% of participants considered charcoal burning to be an easily accessible suicide method. Multivariable analyses revealed that among the examined factors, the perceived ‘painlessness’ of charcoal-burning suicide was associated with an over seven-fold increased risk of choosing charcoal-burning suicide (OR = 7.394; p < 0.001; 95% CI: 2.614–20.912).

Conclusion

As reflected in this study, charcoal-burning suicide is perceived as easily accessible and painless. The perceived ‘painlessness’ may be the factor that distinguishes the choice of charcoal-burning suicide from that of other suicide methods. Future efforts to target these perceptions regarding charcoal-burning suicide may be warranted in both media reporting and suicide prevention programmes.

Global burden analysis and AutoGluon prediction of accidental carbon monoxide poisoning by Global Burden of Disease Study 2019

Accidental carbon monoxide poisoning (ACOP) is the most common occupational toxic disease, but related data are scarce or non-existent in many countries. This article investigates the global burden of ACOP based on the Global Burden of Disease Study 2019 (GBD 2019) and the World Bank database. In our study, numbers and age-standardized rates of ACOP prevalence, incidence, deaths, disability-adjusted life years (DALYs), years lived with disability (YLDs), and years of life lost (YLLs) were analyzed at global, regional, and national level. Besides, the estimated annual percentage change (EAPC) of age-standardized rates were calculated by generalizing the linear model. Age, sex, and Socio-demographic Index (SDI) are included to access their internal relevance. Globally, in 2019, there were approximately 0.97 million ACOP incidence cases (95% CI 0.66 million to 1.4 million), and 41,142 (95% UI 32,957 to 45,934) people died from it. Compared with 1990, the morbidity and mortality of ACOP in 2019 are on a downward trend. By sexes, from 1990 to 2019, females have higher morbidity and lower mortality. This correlation enables us to evaluate the level and status of public health services in various countries. We also evaluated the correlation between ACOP and economic parameters and use newly released machine learning tool-AutoGluon to predict the epidemiology of ACOP. The results of this study can be used by the health authorities to consider the burden of ACOP that could be addressed with preventive and therapeutic measures.

Analysing the Impacts of Financial Expenditure of Prefectures on Methods of Suicide Completion in Japan

Recently, several studies reported that the governmental financial expenditures play important roles in the prevention of increasing suicide mortalities; however, the specific regional policies, designed dependent on regional cultural, economic, education and welfare backgrounds, affect suicide mortality by a specific suicidal means. Therefore, the present study determined the impacts of the regional governmental expenditure of six major divisions, “public health”, “public works”, “police”, “ambulance/fire services”, “welfare” and “education” on suicide mortalities by five major suicidal means, “hanging”, “poisoning”, “charcoal burning”, “jumping” and “throwing”, across the 47 prefectures in Japan during 2009–2018 using fixed-effect analysis of hierarchal linear regression with robust standard error. The expenditures of “ambulance/fire services” and “education” indicated the negative relation to suicide mortalities by wide-spectrum suicidal means, whereas expenditures of “public works” did not affect suicide mortalities. In the education subdivisions, expenditure of “kindergarten” and “elementary school” indicated the impacts of reduction of suicide mortalities, whereas the expenditures of “special school” for individuals with disabilities unexpectedly contribute to increasing suicide mortalities by poisoning, charcoal burning and throwing of females. Regarding subdivisions of welfare, expenditure of “child welfare” and “social welfare” contributed to a reduction in suicide mortalities, but expenditure of “elderly welfare” surprisingly contributed to increasing suicide mortalities. Furthermore, expenditures of welfare subdivision abolished the negative impacts of the expenditures of educational subdivisions, kindergarten and elementary school, but the positive impact of expenditure of special school on female suicide mortalities was not affected. These results suggest that most Japanese people are struggling to care for children even in the situation of an increasing elderly population with a decreasing birthrate. Therefore, it is important to enhance the investment welfare policy for the future to improve the childcare environment. The results demonstrated by this study suggest that the scientifically evidence-based redistributions of welfare expenditure in regional government, at least partially, provide improvement of Japanese society and welfare systems, under the continuous severe Japanese social concerns associated with increasing elderly population with a decreasing birthrate.

The Age-Period-Cohort trends of suicide in Hong Kong and Taiwan, 1979-2018

BACKGROUND

The global age-standardized suicide rate fell by 32.7% between 1990 and 2016. The decrease was largely due to suicide rate reductions in China and India. High-income Asian regions did not see such reductions. The aim of the current study was to explore recent suicide rate trends in Hong Kong and Taiwan to decompose which factors - age, period or cohort - explain suicide rate changes in these two regions.

METHODS

Official mortality data for 1979-2018 in Hong Kong and Taiwan were collected. We utilized Web Tool from the NIH (National Institute of Health, USA) to analyze the Age-Period-Cohort (APC) effects.

RESULTS

We found marked age-effect that suicide rates increased with age in both genders in both places. Period effect related to the dissemination of charcoal burning suicide was found during 1999-2003 in Hong Kong and 2004-2008 in Taiwan. Increasing suicide rates in the middle- and young-age male cohorts were found in both regions. No increase in suicide risks in young female cohorts was observed. Older cohorts in Hong Kong and older female cohorts in Taiwan also had high suicide rates, but older male cohorts in Taiwan had low rate.

LIMITATIONS

The interpretations and observations at the population level might not hold at the individual level.

CONCLUSIONS

The high suicide risk in middle- and young male cohorts in both regions contribute to the persistent high suicide rates in these two regions. Special attention should be turn to the factors underlying such increasing trends.

Analysing effects of financial support for regional suicide prevention programmes on methods of suicide completion in Japan between 2009 and 2018 using governmental statistical data

OBJECTIVES

To explore the mechanisms of reduction of suicide mortality in Japan (from 25.7 to 16.5 per 100 000 population) between 2009 and 2018, the present study determined the effects of execution amounts of regional suicide prevention programmes (Emergency Fund to Enhance Community-Based Suicide Countermeasure: EFECBSC) on gender-specific trends of suicide mortality by disaggregated methods.

DESIGN AND SETTING

Stepwise multiple regression analysis was used to determine the effects of execution amounts of 10 subdivisions of execution amounts of financial support for regional suicide prevention programmes (EFECBSC) on suicide methods and gender disaggregated suicide mortalities in Japan between 2009 and 2018 using the statistical data obtained from national governmental database.

RESULTS

The suicide mortalities by the most common/frequent suicide methods, hanging, charcoal burning and jumping were significantly decreased between 2009 and 2018. Male hanging suicide was decreased by prefectural enlightenment, municipal development programmes, but female hanging suicide was decreased by municipal personal consultation programmes. Municipal development and enlightenment programmes decreased male and female charcoal-burning suicide mortalities, respectively. Jumping suicide was decreased by prefectural telephone consultation programmes but was unexpectedly increased by municipal personal consultation and enlightenment programmes.

CONCLUSIONS

This study revealed the contribution of ECEFBSC on reduction of suicide mortalities, especially hanging, charcoal-burning and jumping suicides, via enhancement of regional suicide prevention programmes in Japan; however, notably, the 'means substitution' from parts of hanging and charcoal burning to jumping is probably generated by EFECBSC. Therefore, these findings provide important aspects for planning evidence-based and cost-effective regional suicide prevention programmes.

Incidence and method of suicide mortality in patients with schizophrenia: a Nationwide Cohort Study

PURPOSE

Suicide is a leading cause of death in patients with schizophrenia. This nationwide cohort study investigated the incidence of each suicide method in patients with schizophrenia compared with the general population.

METHODS

In total, records of 174,039 patients with schizophrenia were obtained from the National Health Insurance Research Database in Taiwan from 2001 to 2016. This schizophrenia cohort was linked with the national mortality database, and 26,926 patients died during this follow-up period. Of the deceased, 3033 had died by suicide. Univariate Cox regression was used to estimate the demographic variables associated with suicide. We estimated the difference in the proportion of each suicide method used in patients with schizophrenia compared with the general population. The incidence and standardized mortality ratio (SMR) of each suicide method were calculated and stratified based on sex.

RESULTS

Patients aged 25-34 years exhibited the highest suicide risk. Compared with the general population, patients with schizophrenia were more likely to commit suicide by jumping and drowning and less likely to use charcoal-burning and hanging. Women showed a higher incidence of suicide by drowning and jumping than did men. Comorbidity with substance use disorders (SUDs) was associated with a high suicide SMR (26.9, 95% confidence interval [CI] = 23.4-28.9), particularly for suicide by jumping (61.2, 95% CI = 48.3-76.3).

CONCLUSIONS

Patients with schizophrenia had higher suicide rates for all methods than did the general population. Suicide method differed based on sex. Patients with SUDs exhibit a high SMR for each suicide method and warrant intensive clinical attention.

Changes in the epidemiological profile of suicide in Hong Kong: a 40-year retrospective decomposition analysis

The suicide rate in Hong Kong has increased significantly over the past four decades. Population subgroups such as the elderly or economically-distressed are reported to be more vulnerable than others to suicidal behaviors, while changing suicide methods (such as charcoal burning which emerged in 1998), has also contributed significantly to increasing suicide rates. However, the extent of the contribution of different factors to changes in suicide rate remains unclear. This paper reported on a decomposition analysis of the epidemiological profile of suicide in Hong Kong between 1976 and 2015, specifically considering factors underlying the increasing suicide rate over this period. Completed death registry information was available from the Census and Statistics Department of the Hong Kong SAR for this investigation. We compared absolute and relative contributions of gender, age and suicide method to rate changes over time. Changes in suicide rate were generally underpinned by more than one factor. Population aging in a rapidly-aging city contributed significantly to suicide rate increases, whilst jumping from a height had the greatest influence on rate changes throughout the study period. Suicides by male aged 25-34 years and 45-54 years were more likely to be triggered by economic factors, compared with the other gender-age subgroups. The decomposition approach provided a comprehensive understanding about how socioeconomic factors and suicide methods interacted to influence over-time suicide patterns. This research supports development of more focused suicide prevention measures to reduce suicide rate.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s42379-021-00087-5.

Method-Specific Suicide Rates and Accessibility of Means

Abstract.Background: Few studies have investigated whether means accessibility is related to the spatial distribution of suicide. Aims: To examine the hypothesis that indicators of the accessibility to specific suicide methods were associated with method-specific suicide rates in Taipei City, Taiwan. Method: Smoothed standardized mortality ratios for method-specific suicide rates across 432 neighborhoods and their associations with means accessibility indicators were estimated using Bayesian hierarchical models. Results: The proportion of single-person households, indicating the ease of burning charcoal in the home, was associated with charcoal-burning suicide rates (adjusted rate ratio [aRR] = 1.13, 95% credible interval [CrI] = 1.03–1.25). The proportion of households living on the sixth floor or above, indicating easy access to high places, was associated with jumping suicide rates (aRR = 1.16, 95% CrI, 1.04–1.29). Neighborhoods’ adjacency to rivers, indicating easy access to water, showed no statistical evidence of an association with drowning suicide rates (aRR = 1.27, 95% CrI = 0.92–1.69). Hanging and overall suicide rates showed no associations with any of these three accessibility indicators. Limitations: This is an ecological study; associations between means accessibility and suicide cannot be directly inferred as causal. Conclusion: The findings have implications for identifying high-risk groups for charcoal-burning suicide (e.g., vulnerable individuals living alone) and preventing jumping suicides by increasing the safety of high buildings.

Assessing the effect of restricting access to barbecue charcoal for suicide prevention in New Taipei City, Taiwan: A controlled interrupted time series analysis

BACKGROUND

Suicides by carbon monoxide poisoning from burning charcoal increased markedly and contributed to a rise in overall suicides in Taiwan in the early 2000s. A previous study indicated short-term effectiveness on reducing suicides of a charcoal restriction programme, which involved voluntary actions from large chain retail stores to move charcoal bags from open shelves to locked cabinets starting from 1st May 2012, in New Taipei City, Taiwan. We investigated the longer-term effect of this programme.

METHODS

We calculated quarterly age-standardised charcoal-burning and overall suicide rates in New Taipei City and two comparison cities in 2007-2017. Controlled interrupted time-series analysis was used to examine the effect of the charcoal restriction programme.

RESULTS

There was no difference between the intervention and comparison cities in step changes in the rates (per 100,000) of charcoal-burning suicide (intervention minus comparison = -0.336, 95% confidence interval -1.173 to 0.502) and overall suicide (-0.270, -1.844 to 1.303) after the intervention, or changes in trends (slopes) in charcoal-burning suicide rates (0.007, -0.055 to 0.069) and overall suicide rates (0.049, -0.138 to 0.236) before and after the intervention.

LIMITATIONS

There was no legislative requirement to enforce the charcoal restriction. The programme was also restricted to a subset of retail stores.

CONCLUSION

The charcoal restriction programme in New Taipei City showed no effect on reducing charcoal-burning or overall suicides in the five years after its implementation. Future means restriction strategies for suicide prevention should optimise the programme sustainability, ensure the comprehensive means restriction, and monitor the long-term intervention effectiveness.

Gender difference in suicide in Taiwan over a century: a time trend analysis in 1905-1940 and 1959-2012

BACKGROUND

Suicide rates are higher in men than in women in most countries, although the gender ratios vary markedly worldwide. We investigated long-term trends in suicide rates and the male-to-female ratios in relation to age, method and economic factors in Taiwan during the Japanese colonial (1905-1940) and postwar (1959-2012) periods.

METHODS

Suicide data were from the Statistical Reports of Taiwan Governor's Office (1905-1940), Vital Statistics (1959-1970) and cause-of-death mortality data files (1971-2012). Annual age-standardised and age-specific/method-specific suicide rates by gender and the gender ratios were calculated and examined graphically. The associations between trends in economic indicators, suicide and suicide gender ratio were investigated using Prais-Winsten regression.

RESULTS

The male-to-female suicide rate ratio increased from below 1 in the 1900s to around 2 by 2000; the reversal was mainly due to a marked reduction in suicide rates in young women coupled with a rise in male suicide between 1905 and 1940. The gender ratio increased again from the 1980s onwards. Poisoning was the most common method in the 1970s-1980s, but its use decreased afterwards, more in women than in men proportionally. The use of gassing for suicide increased markedly in the 2000s and contributed to the rises in overall suicide and the gender ratio. Unemployment rates were more strongly associated with male suicide than female suicide in 1959-2012. Unemployment rates and gross domestic product per capita were positively associated with suicide gender ratios.

CONCLUSIONS

Gender differences in suicide changed remarkably in Taiwan over the past century; such change may be related to cultural, socioeconomic and method-specific factors.

Sex-specific and age-specific suicide mortality by method in 58 countries between 2000 and 2015

Objective

To examine recent changes in sex-specific and age-specific suicide mortality by method across countries.

Methods

Using mortality data from the WHO mortality database, we compared sex-specific, age-specific and country-specific suicide mortality by method between 2000 and 2015. We considered seven major suicide methods: poisoning by pesticides, all other poisoning, firearms and explosives, hanging, jumping from height, drowning and other methods. Changes in suicide mortality were quantified using negative binomial models among three age groups (15–44 years, 45–64 years, and 65 years and above) for males and females separately.

Results

Suicide mortality declined substantially for both sexes and all three age groups studied in 37 of the 58 included countries between 2000 and 2015. Males consistently had much higher suicide mortality rates than females in all 58 countries. Hanging was the most common suicide method in the majority of 58 countries. Sex-specific suicide mortality varied across 58 countries significantly for all three age groups. The spectrum of suicide method generally remained stable for 28 of 58 included countries; notable changes occurred in the other 30 countries, including especially Colombia, Finland and Trinidad and Tobago.

Conclusion

Likely as a result of prevention efforts as well as sociodemographic changes, suicide mortality decreased substantially in 37 of the included 58 countries between 2000 and 2015. Further actions are needed to explore specific drivers of the recent changes (particularly for increases in eight countries), to understand substantial disparities in suicide rates across countries, and to develop interventions to reduce suicide rates globally.

Incidence Rate and Predictors of Globus Pallidus Necrosis after Charcoal Burning Suicide

Objective: This study examined predictors of globus pallidus necrosis as there was a paucity of literature of globus pallidus necrosis resulted from carbon monoxide poisoning after charcoal burning suicide. Methods: A total of 67 patients who had attempted charcoal burning suicide were recruited and stratified into two subgroups based on either presence (n = 40) or absence (n = 27) of globus pallidus necrosis. Demographic, clinical, laboratory, and radiographic data were obtained for cross-sectional analysis. All patients were followed to investigate the risks for mortality. Results: The patients aged 36.8 ± 11.1 years (67.2%) were male. Patients with globus pallidus necrosis were younger (p = 0.044) and had less hypertension (p = 0.015) than patients without globus pallidus necrosis. Furthermore, patients with globus pallidus necrosis suffered from severer medical complications, i.e., fever (p = 0.008), acute myocardial injury (p = 0.022), acute rhabdomyolysis (p = 0.022), and neuropsychiatric symptoms (p < 0.001) than patients without globus pallidus necrosis. Moreover, patients with globus pallidus necrosis received less hyperbaric oxygen therapy than without necrosis (p = 0.024). Two patients (3.0%) died on arrival. In a multivariable regression model, it was revealed that acute myocardial injury (odds ratio 4.6, confidence interval 1.1–18.9, p = 0.034) and neuropsychiatric symptoms (odds ratio 8.0, confidence interval 2.0–31.4, p = 0.003), decreased blood bicarbonate level (odds ratio 0.8, confidence interval 0.7–1.0, p = 0.032), and younger age (odds ratio 0.9, confidence interval 0.9–1.0, p = 0.038) were significant predictors for globus pallidus necrosis. Conclusion: Although patients who had attempted charcoal burning suicide had a low mortality rate (3.0%), globus pallidus necrosis was not uncommon (59.7%) in this population. Further studies are warranted.

Suicide Means Used by the Older Adults in Rural China: A Comparison Between Those Using Pesticides and Other Means

BACKGROUND

The most frequently used means of committing suicide was pesticide poisoning in rural China, yet little is known about the characteristics and risk factors for suicides committed with pesticides compared to those committed via other means in older adults.

METHODS

The participants were 242 older adults (aged 60 or older) who had committed suicide in the rural areas of 3 provinces (Shandong, Hunan, and Guangxi) in China. This study was conducted using the psychological autopsy (PA) method.

RESULTS

In univariate analyses, no statistically significant differences were found between those who committed suicide with pesticide or with other means in terms of demographic and clinical variables except age, prevalence of mental disorders, suicidal intent, number of recent life events, social support, hopelessness, impulsivity, and depressive symptoms (P > .05); age, history of suicide attempts, having pesticides available at home, the total number of life events, and the number of long-term life events were significantly different (P < .05) between the 2 groups. In multivariate logistic regression model, the factors associated with committing suicide with pesticides were the availability of pesticides at home (odds ratio [OR] = 3.48, 95% confidence interval [CI]: 1.99-6.08) and the number of long-term life events (OR = 0.87, 95% CI: 0.78-0.97).

CONCLUSION

The older adults who committed suicide by pesticides and those using other means are probably the same population. The main determinant of choosing pesticides as suicide means was likely the availability of pesticides at home. Suicide risk among older adults might be reduced by placing appropriate restrictions on access to pesticides.

The evolution of the characteristics of charcoal-burning suicide in Hong Kong, 2002-2013

BACKGROUND

The use of barbecue charcoal gas for suicide led to more than 50,000 deaths in Asia since the rise of its use from 1998. Little is known whether the profile of charcoal-burning suicides changed over time.

METHODS

Hong Kong's suicide data (2002-2013) were extracted from the Coroner's files. The detailed characteristics were compared between suicide by charcoal-burning and non-charcoal-burning methods, and between charcoal-burning suicides of different periods (2002-2005 vs 2006-2009 vs 2010-2013).

RESULTS

People who died by suicide using charcoal burning (n = 2,188) were more likely to be male, aged 30-49 years, married (2002-2005 only), have debt, or live alone, and were less likely to have past or current psychiatric treatment or medical illness than non-charcoal-burning suicides (n = 9,666) across the three four-year periods. By contrast, compared to charcoal-burning suicides in 2002-2005, those in more recent periods (2006-2009 and 2010-2013) were more likely to be aged 50+, non-married, live alone (2006-2009 only), or have current psychiatric treatment or medical illness, and were less likely to be male (2006-2009 only), unemployed, or have debt.

LIMITATIONS

There could be under-reporting of certain characteristics for charcoal-burning suicides in the Coroner's files.

CONCLUSION

Charcoal-burning suicides persistently showed a distinguishable profile in Hong Kong, whilst changes in certain characteristics suggested a 'diffusion' of the method to some other groups such as older individuals. Responsible media reporting and restricting online information about new suicide methods could be potentially important prevention strategies in the early stage, whilst other strategies are needed when the methods become more commonly used.

Characteristics of unnatural deaths in Tierra del Fuego, Argentina: A 10-year study (2008-2017)

A retrospective review was undertaken of 287 unnatural deaths undergoing medicolegal investigation over a 10-year period from January 2008 to December 2017 in Rio Grande, Tierra del Fuego, Argentina. There were 219 males and 68 females, age range 7 months to 88 years (average 38.4 years). The 135 accidental deaths (47%) were due mainly to vehicle crashes ( N = 62) and carbon monoxide toxicity from fires ( N = 31). The 115 cases of suicides (40.1%) were predominantly due to hanging ( N = 75) and gunshot wounds ( N = 20). The 37 cases of homicide (12.9%) were mainly due to stabbing/sharp force injury ( N = 20) and blunt force trauma ( N = 9). Carbon monoxide toxicity from faulty heating accounted for a substantial percentage (8.1%) of the accidental deaths. Firearm homicides and suicides related to drug toxicity and carbon monoxide inhalation were relatively uncommon medicolegal cases in this centre.

The trend in mortality due to suicide in urban and rural areas of Colombia, 1979-2014

Introduction: Suicide is a serious social and public health problem that affects the population in most countries in the world. Differences in suicide rates in rural and urban areas have been previously described. Objective: To study the trend of mortality rates by suicide in Colombia, in rural and urban areas by gender, age group, and suicide method during the years 1979-2014. Materials and methods: We conducted a temporal trend ecologic study using death certificates from the Departamento Administrativo Nacional de Estadística, DANE. Specific and adjusted by age and gender mortality rates were calculated. We estimated negative binomial and inflection point regression models to study the trends in mortality rates stratified by gender, age group, and suicide method. Results: A total of 56,448 suicides was reported in Colombia between 1979 and 2014. The risk of suicide was higher in urban areas for men, individuals between 25 and 44 years, and 65 and over; and for those who used hanging as the suicide method. Also, the risk of suicide was higher in the rural area for men between 45 and 64 years old, and those who used firearms, sharp weapons, hanging, and others as suicide methods. The trend of suicide rates in urban areas showed its maximum peak in 1999 and in the rural ones in 2000. Then, in the two areas, there was a gradual decrease. Hanging in both areas presented a tendency to rise in men. Conclusions: Suicide has shown a tendency toward reduction after the year 2000, with differences between urban and rural areas.

Evidence-Based Suicide Prevention: Collective Impact of Engagement with Community Stakeholders

Purpose: In response to the rising suicide trend in Hong Kong, the Centre for Suicide Research and Prevention ("CSRP") was established in 2002, with the aim to capitalize on the collective impact of research-support practices to prevent suicides.Method: The CSRP has since become an international knowledge hub that applies a public health approach and innovative strategies to address suicide-related problems at multiple levels.Results: The CSRP actively engages in research, teaching, and knowledge exchange with community stakeholders. These effort are associated with Hong Kong's more than 30% reduction in suicide rates between 2003 and 2016.Discussion: The rationale for and examples of the CSRP's practices in face of the suicide prevention challenges lay ahead were also discussed.Conclusion: The outcomes of these practices, which hold great potential for suicide prevention worldwide, have contributed to important academic debates in the field of suicidology.

Suicide deaths by gas inhalation in Toronto: An observational study of emerging methods of suicide

BACKGROUND

Suicide death by gas inhalation has been the subject of global scientific interest due to a rapid increase in the use of helium and charcoal gas for suicide. These may be particularly amenable to means restriction strategies. There has been little scientific attention of this phenomenon in Canada.

METHODS

A review of coroner records was conducted for all suicide deaths in Toronto (1998-2015). Deaths were categorized as due to inhalational asphyxia by compressed gas (i.e. helium or nitrogen), charcoal burning or motor vehicle exhaust, with suicide deaths by other methods as a comparator. Demographic, clinical and suicide specific differences between decedents in these four categories were compared using chi-squared or ANOVA global test of significance with additional pairwise comparisons where appropriate. Secular trends were also examined.

RESULTS

Gas inhalational deaths accounted for 190 (4.7%) of all suicides in Toronto (n = 4062) over the study period and a higher proportion of males used compressed gas or motor vehicle exhaust gases than those who died by other methods (83.3% and 84.0% vs.69.7%, both p = 0.01). Comparing 1998-2003 to 2010-2015 there was a 1075% increase in deaths by helium (4 vs. 43 deaths) and a 533% increase in deaths by charcoal burning (3 vs. 16 deaths) although helium and charcoal burning deaths still accounted for only 4.2% of total suicides 2010-2015. Deaths by helium were more likely to be accompanied by the book "Final Exit" than those by non-inhalational methods (15% vs. 0.7%, p < 0.0001) while 13 of 14 people who died by charcoal burning whose ethnicity could be determined were Asian.

LIMITATIONS

Ethnicity and specific details of procurement of suicide methods were not systematically available in coroner records.

DISCUSSION

Suicide by inhalational asphyxia, particularly by compressed gases, has increased substantially over time in Toronto consistent with observations in other countries. Increased surveillance of these deaths, efforts to restrict access to these methods, and timely interventions including minimizing media reporting are all warranted.

Differences between patterns of suicide in East Asia and the West. The importance of sociocultural factors

OBJECTIVE

To compare suicide rates and characteristics in East Asian and Western countries.

METHOD

Data from five East Asian jurisdictions and five English-speaking Western countries were obtained from national offices responsible for collection of statistics. Data were graphed to demonstrate differences between East Asian and Western age patterns of suicide. Relevant literature was reviewed, including observations concerning suicide rates in various non-English-speaking European countries.

RESULTS

Age patterns and rates of suicide differ between East and West and across time, but with Japan's and the United States patterns progressively becoming more similar.

CONCLUSIONS

Sociocultural factors affect suicide patterns and rates; choice of method and cohort effects affect rates. Strategies for prevention of suicide should give attention to culture-related precipitants of suicide.

Risk of dementia after charcoal-burning suicide attempts: a nationwide cohort study in Taiwan

This study aimed to investigate the association between charcoal-burning suicide attempts and the risk of developing dementia. A nationwide, matched cohort, population-based study enrolled a total of 4103 patients with newly diagnosed charcoal-burning suicide attempts, between 2000 and 2010, which were selected from the National Health Insurance Research Database of Taiwan, along with 12,309 controls matched for sex and age. After adjusting for confounding factors, Fine and Gray's competing risk analysis was used to compare the risk of developing dementia during the 10-year follow-up period. Of the enrolled patients (n=16,412), dementia developed in 303 (1.85%), including 2.56% in the study group (105 in 4103) and 1.61% (198 in 12,309) in the control group. The Fine and Gray's survival analysis revealed that the patients with charcoal-burning suicide attempts were likely to develop dementia, with a crude HR of 5.170 (95% CI 4.022 to 6.644, p<0.001). After adjusting for age, sex, comorbidity, geographic area and urbanization level of residence, and monthly insured premium, the adjusted HR was 4.220 (95% CI 3.188 to 5.586, p<0.001). Suicide attempts were associated with an increased risk of degenerative dementia in this study. Patients with charcoal-burning suicide attempts had a fourfold risk of dementia than the control group.

Sciatic neuropathy and rhabdomyolysis after carbon monoxide intoxication: A case report

RATIONALE

Peripheral neuropathy is a rare complication of carbon monoxide intoxication. Peripheral neuropathy following carbon monoxide intoxication is known to completely recover within a few months.

PATIENT CONCERNS

A 40-year-old man complained of motor weakness and hypoesthesia of the right lower extremity with swelling of his right thigh after carbon monoxide intoxication resulting from a suicide attempt.

DIAGNOSES

Following nerve conduction and electromyographic studies, the patient was diagnosed with sciatic neuropathy with severe axonopathy. Clinical and laboratory findings led to a diagnosis of rhabdomyolysis.

INTERVENTIONS

The patient was treated conservatively for rhabdomyolysis and underwent comprehensive rehabilitation for sciatic neuropathy during hospitalization.

OUTCOMES

After discharge, he underwent serial follow-up tests with nerve conduction and electromyographic studies, which showed prolonged persistence of sciatic neuropathy; however, he showed significant improvement at his 26-month post-discharge follow-up.

LESSON

Patients presenting with peripheral neuropathy secondary to carbon monoxide intoxication may show variable recovery periods; however, a favorable prognosis can be expected regardless of the concomitant occurrence of rhabdomyolysis and/or compartment syndrome.

Suicide deaths among patients with end-stage renal disease receiving dialysis: A population-based retrospective cohort study of 64,000 patients in Taiwan

BACKGROUND

Patients with end-stage renal disease (ESRD) who receive dialysis may experience increased distress and risk of suicide.

METHODS

This population-based retrospective cohort study linked Taiwan's national register of ESRD patients on dialysis and the cause-of-death mortality data file. A separate multiple-cause-of-death data file was used to investigate the detailed suicide methods used. Standardized mortality ratios (SMRs) were calculated for the overall patient group and by sex, age, year of initiating dialysis, method of suicide, and time since initiation of dialysis.

RESULTS

Among 63,854 ESRD patients on dialysis, 133 died by suicide in Taiwan in 2006-2012; the suicide rate was 76.3 per 100,000 patient-years. The SMR for suicide was 2.38 (95% confidence interval [CI] 1.99-2.82) in this patient group. Suicide risk was highest in the first year of dialysis (SMR = 3.15, 95% CI 2.39-4.08). The risk of suicide by cutting was nearly 20 times (SMR = 19.91, 95% CI 12.88-29.39) that of the general population. Detailed information on death certificates indicated that three quarters of patients who killed themselves by cutting cut vascular accesses used for hemodialysis.

LIMITATIONS

Information on risk factors such as socioeconomic position and mental disorders was unavailable.

CONCLUSION

In a country where the national health insurance program covers most expenses associated with dialysis treatment, the suicide risk in ESRD patients on dialysis still increased nearly 140%. Adequate support for ESRD patients initiating dialysis and the assessment of risk of cutting vascular access as a potential means of suicide could be important strategies for suicide prevention.

Point-of-care testing in the early diagnosis of acute pesticide intoxication: The example of paraquat

Acute pesticide intoxication is a common method of suicide globally. This article reviews current diagnostic methods and makes suggestions for future development. In the case of paraquat intoxication, it is characterized by multi-organ failure, causing substantial mortality and morbidity. Early diagnosis may save the life of a paraquat intoxication patient. Conventional paraquat intoxication diagnostic methods, such as symptom review and urine sodium dithionite assay, are time-consuming and impractical in resource-scarce areas where most intoxication cases occur. Several experimental and clinical studies have shown the potential of portable Surface Enhanced Raman Scattering (SERS), paper-based devices, and machine learning for paraquat intoxication diagnosis. Portable SERS and new SERS substrates maintain the sensitivity of SERS while being less costly and more convenient than conventional SERS. Paper-based devices provide the advantages of price and portability. Machine learning algorithms can be implemented as a mobile phone application and facilitate diagnosis in resource-limited areas. Although these methods have not yet met all features of an ideal diagnostic method, the combination and development of these methods offer much promise.

Neurotoxicity of carbon monoxide targets caudate-mediated dopaminergic system

The clinical features of parkinsonism in carbon monoxide (CO) intoxication have been associated with striatal-related neuronal networks. As parkinsonian and neuropsychiatric features are both related to presynaptic dopaminergic integrity, the aim of this study was to explore the clinical significance of ^99mTcTRODAT-1 in grading neurobehavioral scores and parkinsonian severity in CO intoxication. We enrolled 64 patients with CO intoxication, including 29 with parkinsonism (parkinsonism[+] group) and 35 without (parkinsonism[-] group). All of the patients received ^99mTcTRODAT-1 neuroimaging evaluations, comprehensive neurobehavioral tests and assessments of the severity of parkinsonism using Unified Parkinson's Disease Rating Scale (UPDRS)-part III motor score. Univariate and multivariate regression analyses were used to test the predictive factors and scores for a diagnosis of parkinsonism and its severity. The parkinsonism(+) group had significantly lower cognitive scores and higher neuropsychiatric total scores compared with the parkinsonism(-) group, both of which were independently related to the severity of parkinsonism. ^99mTcTRODAT-1 regional caudate signals were correlated with tremors at rest, action or postural tremors of the hands, bradykinesia and hypokinesia, and visuospatial, verbal fluency, abstract thinking and digit backwards scores. Scores of the neurobehavioral tests and UPDRS items were highly correlated (p<0.01). Our results validated the initial hypothesis in that neurobehavioral deficits and parkinsonian symptoms were highly related. This association was independent of demographic factors and initial carboxyhemoglobin level. Within the presynaptic dopaminergic circuit, the clinical role of the caudate in mediating the clinical symptoms in CO intoxication may outweigh the putamen.

Themes and trends in intentional self-poisoning: Perspectives from critical care toxicology

This research investigated the substances employed by and experiences of patients who come to acute treatment after self-poisoning. A retrospective search of the Toxicology Investigators Consortium Registry was performed to characterize a large cohort of patients. A detailed prospective study of one inpatient toxicology service was also conducted. Patients chose readily available agents for self-poisoning. Most cases involved at least one substance that affects the central nervous system (CNS). The majority were prescription psychotropics and narcotics. When they had access to both CNS-active and CNS-inactive medications, patients almost invariably ingested a mind-altering agent. After recovering neurocognitive function, most patients were not actively experiencing suicidal thoughts. However, more than half of patients without CNS toxicity continued to have suicidal ideation after coming to care. These findings are consistent with the hypothesis that many suicidal patients may be seeking an altered psychosomatic state rather than death per se.

A Public Health Approach in Responding to the Spread of Helium Suicide in Hong Kong

Abstract. Background: The use of the helium suicide method has been increasing in popularity in Hong Kong since 2012. We have learned a valuable lesson in curbing the spread of charcoal burning (CB) suicide in the past 15 years and hope to prevent the helium suicide method from taking off in the community. Aims: To document what actions have been taken to contain the spread of the helium suicide method and review the preliminary impact of these actions. Method: We adopted a public health approach by engaging stakeholders from multiple sectors, including the police force, the fire services department, coroners, pathologists, mass media, and online media outlets. Results: A monitoring system was established by compiling data extracted from news reports, coroners' reports, and police investigations. Risk and protective factors were identified. Intervention strategies were developed to strengthen protective factors and minimize risk factors. This novel suicide method has not spread as rapidly as the CB suicide method. The preliminary outcomes suggest our actions to be effective. Limitations: The count of helium suicides in 2015 might be low. The impacts of the interventions are only estimated and require additional empirical verifications. Conclusion: The public health approach of engaging multiple partners in the early phase of a potential epidemic can be a good guide to meeting the challenges posed by any new suicide methods that emerge in the future.

Media effects on suicide methods: A case study on Hong Kong 1998-2005

Background

Previous studies have suggested that mass media’s reports of new suicide methods will increase suicides using the same method. The same pattern seems not to apply to a conventional suicide method, unless it was used by a celebrity.

Objective

1) to examine media effects on both new and non-new suicide methods during 1998 and 2005 in Hong Kong (HK), when a new method by burning charcoal (CB suicide) was spreading in the region. 2) to examine how CB competed with non-CB methods in terms of media coverage and “recruiting” suicidal persons in the socio-economic context.

Methods

A self- and mutual- exciting process model was fitted to the data, adjusting for divorce rate, unemployment rate, and property price index. Breaking the whole period into onset, peak, and post-peak stages, the model was fitted again to examine the differences.

Results

Comparable copycat effects were found on both CB and non-CB suicide news. The only cross-method media effects were found in the onset stage when non-CB suicide news showed suppressing effect on CB suicides. CB suicides reported a significant self-excitation effect. A higher divorce rate and lower property price index were associated with significantly more suicides incidences and more suicide news.

Conclusions

The emerging of CB suicide method did not substitute media coverage of non-CB suicide in HK. Media effects in this case were not limited to new suicide method or celebrity suicide. The effects were further fueled by adverse socio-economic conditions.

Changes in age patterns of suicide in Australia, the United States, Japan and Hong Kong

The patterns of association between age and suicide rate vary by country, subpopulation and gender, and over time. To shed light on factors associated with these differences, we analysed suicide data from four populations, two 'Western' (Australia, the United States [US]) and two Asian (Japan and Hong Kong). We computed suicide rates in five-year age-groups (between 10 and 14 years and 85+ years) for men and women separately, and present graphical representations of the age patterns during selected five-year periods. Rates and age patterns differed markedly, as did gender patterns except in Hong Kong. In 1964-8, male suicide rates in Australia and US were represented by upward-sloping graphs, whereas in Japan the pattern was bimodal. By 1979-83, male patterns in Australia and US were bimodal, but Japan's was trimodal, including a middle-age peak reached in 1994-98. In contrast, female age patterns in the Western countries were shallowly convex or uniform, while in Hong Kong and Japan the upward-sloping graphs became, over time, less steep; by 2009-13, the pattern in Japan was uniform (flat). In recent decades, suicide rates of older men in Australia, US and Japan, and older women in Japan and Hong Kong, have fallen considerably. Suicide rates of men aged 45-64 in Australia and US also fell, though by 2009-13 the US rate had risen again. The suicide rate of Australian men in their twenties halved between 1994-98 and 2009-13, while rates for younger men and women in Japan have risen since 1994-98. In Hong Kong, suicide rates of young men have increased. Age patterns of suicide likely reflect period and cohort effects shaped by socioeconomic stressors, availability of health and welfare services, access to lethal methods of suicide, and other factors. Greater understanding of their impact on age patterns of suicide can result in potential preventive solutions.

Suicide rate trends in the Slovak Republic in 1993-2015

BACKGROUND

Suicide is a significant public health issue worldwide, resulting in loss of lives, and burdening societies.

AIMS

To describe and analyze the time trends of suicide rates (SRs) in the Slovak Republic in 1993-2015 for targeted suicide prevention strategies.

METHODS

Data for this study were obtained from the mortality database of the Statistical Office of the Slovak Republic. Crude and standardized annual SRs were calculated. Trends and relative risks of suicide according to age and sex were analyzed by joinpoint regression and negative binomial regression.

RESULTS

In total, there were 14,575 suicides in the Slovak Republic in the period 1993-2015 (85.3% were men). The overall average age-standardized SR for the study period was 11.45 per 100,000 person years. The rate increases with age, the highest is in men aged 75+ (42.74 per 100,000 person years). Risk of suicide is six times higher in men than in women and nine times higher in men than in women in the age group 25-34. The time trend of SRs is stable or decreasing from 1993 to 2007, but increasing after 2007, corresponding with increased unemployment rate in the country.

CONCLUSION

The SR in the Slovak Republic is slightly below the average of Organisation for Economic Co-operation and Development (OECD) nations. Highest SR is observed in men of working age and in retirement. Society might benefit from a strategy of education for improving the recognition of suicide risks.

Suicide by pesticide poisoning remains a priority for suicide prevention in China: Analysis of national mortality trends 2006-2013

BACKGROUND

Despite recent declines, suicide remains a priority for China. Ease of availability of high-lethality suicide methods, such as pesticides and firearms, contributes to the overall incidence and is an important target for suicide prevention. This study investigates whether changes in the distribution of methods of suicide have contributed to the recent reduction in suicide in China.

METHOD

Suicide rates (2006-2013) were calculated using the Chinese Disease Surveillance Points system, stratified by gender, age group, and urban-rural residence, to investigate trends in suicide over the study period. Multilevel negative binomial regression models were used to investigate associations between socio-demographic factors and method-specific suicide.

RESULTS

The most common method of suicide in China for both males and females was pesticide poisoning, followed by hanging. All methods declined over the study period, with the exception of suicide by jumping in males. Suicide rates for pesticide poisoning and for hanging increased exponentially with age in those aged over ≥45 years in both sexes. Pesticide poisoning declined from 55% to 49% of all suicides, while hanging increased from 27% to 31%.

LIMITATIONS

This was an ecological study of a time series of suicide rates, with risk factor adjustment being limited to population-level point estimates derived from a single census.

CONCLUSIONS

Suicide by pesticide poisoning and hanging remain the leading methods of suicide in China. Changes to the safe use of pesticides and targeted prevention initiatives to restrict access, along with socio-economic development and urbanisation, are likely contributors to declines in suicide by pesticide poisoning.

Identifying and Tracking Gas Suicides in the U.S. Using the National Violent Death Reporting System, 2005-2012

INTRODUCTION

Identifying the source and specific type of gas used in suicides is difficult using most data systems owing to limitations in ICD-10 coding. The National Violent Death Reporting System (NVDRS), with its rich collection of both coded and free-text variables, has the potential to overcome these limitations. This study used a multipronged approach to identify gas-specific suicides in NVDRS and to track the incidence of these suicides over time.

METHODS

Using suicide cases from the 16 NVDRS states that participated throughout 2005-2012, free-text and code searches were conducted for four types of variables-incident narratives, coroner/medical examiner cause-of-death statements, cause-of-death codes, and substance names-to identify suicides by carbon monoxide, helium, hydrogen sulfide, and four other gases. All analyses were conducted in 2015.

RESULTS

Approximately 4% (3,242 of 80,715) of suicides recorded in NVDRS over the study period were the result of gas inhalation. Of these, the majority (73%) were carbon monoxide suicides (almost exclusively from motor vehicle exhaust and charcoal burning). Other types of gas (most notably helium), once rare, are now more common: At the start of the study period non-carbon monoxide gas suicides represented 15% of all gas suicides; at the end of the study period, they represented 40%.

CONCLUSIONS

Public health policies to reduce a suicidal person's access to more lethal suicide methods require a reliable source of surveillance data on specific methods used in suicide. Small changes to NVDRS could make it an efficient and nimble surveillance system for tracking these deaths.

Unintentional deaths from carbon-monoxide poisoning due to a traditional practice observed during the post-partum period

Deaths resulting from carbon-monoxide poisoning have been reported in the medical literature under diverse circumstances. Here, we report four deaths due to carbon-monoxide poisoning as a result of a traditional practice involving the application of heat to the abdomen to facilitate uterine involution during the immediate post-partum period. Four people died due to carbon-monoxide poisoning in two separate incidents, including two women in the post-partum period. In both instances, the women slept beside a stove with burning charcoal, which was supposed to provide warmth to the lower abdomen.

Recent Advances in Means Safety as a Suicide Prevention Strategy

Despite advances in theory and the development and implementation of evidence-based treatments, the United States suicide rate has been rising continuously for over a decade. Although this does not indicate that traditional treatment approaches should be abandoned, it does highlight the need to supplement such approaches with alternatives. One seemingly highly valuable option is means safety, defined as the reduced access to and/or increased safe storage of potentially lethal methods for suicide. This paper provides a review of the current literature on the prevalence of six methods for suicide and preventative efforts aimed to reduce suicide rates. The majority of means safety interventions seem promising given that these methods are common and highly lethal. However, cultural and practical barriers will need to be taken into consideration when implementing these plans. Overall, means safety efforts and preventative measures seem to be promising ways to reduce the national suicide rate if implemented.

Acute Kidney Injury Predicts Mortality after Charcoal Burning Suicide

A paucity of literature exists on risk factors for mortality in charcoal burning suicide. In this observational study, we analyzed the data of 126 patients with charcoal burning suicide that seen between 2002 and 2013. Patients were grouped according to status of renal damage as acute kidney injury (N = 49) or non-acute kidney injury (N = 77). It was found that patients with acute kidney injury suffered severer complications such as respiratory failure (P = 0.002), myocardial injury (P = 0.049), hepatic injury (P < 0.001), rhabdomyolysis (P = 0.045) and out-of-hospital cardiac arrest (P = 0.028) than patients without acute kidney injury. Moreover, patients with acute kidney injury suffered longer hospitalization duration (16.9 ± 18.3 versus 10.7 ± 10.9, P = 0.002) and had higher mortality rate (8.2% versus 0%, P = 0.011) than patients without injury. In a multivariate Cox regression model, it was demonstrated that serum creatinine level (P = 0.019) and heart rate (P = 0.022) were significant risk factors for mortality. Finally, Kaplan-Meier analysis revealed that patients with acute kidney injury suffered lower cumulative survival than without injury (P = 0.016). In summary, the overall mortality rate of charcoal burning suicide population was 3.2%, and acute kidney injury was a powerful predictor of mortality. Further studies are warranted.